QAT TASK 1

Soap Note on patient SM

Name

Institution affiliation

Soap Note on patient SM

Patient initials: SM

Sex: male

Race: white

Marital status: single

Occupation: Student

Source of information: the patient gives the information and he seems reliable.

Problem Statement

“I am here for a physical test on my right ankle. The ankle got sprained two days ago while I was playing soccer with some of my friends in the football pitch. One of them accidentally hit me. I did not make an earlier visit because I thought the effect was minimal and it would disappear after some time. The pain has been got worse over the last days and most especially during the night.”

Subject

HPI: A 22 white male came for a physical test on a sprained right ankle. The patient states that he is usually in good health. The patient denies case of diarrhea, and hemorrhoids. He denies instances of chest or abdominal pains. The patient denies instances of nausea. The patient claims that he has lost minimal weight over the past six months.

Pertinent Medical Information

Patient denies chronic medical conditions. The last exam for dental and eye were both done in year 2014.

Current Medications

OTC Ibuprofen, 200 mg PO prn ankle pain and Tylenol 1-4/month for headache. The patient should take no prescription medications, supplements or vitamins. The Cholesterol level is low according to 2014 test results.

Allergies

Patient states that he does not suffer any form of allergies.

Preventive Issues

Patient immunization information was unknown and states he has never received a colon screening.

Surgical History

Patient claims he has never undergone a surgery.

Family History

SM lives in a family of five, including his father, mother, brother, sister the patient's father is 47 years old and played football He underwent a vasectomy surgery 10 years ago. The mother is 45 years old and suffers from diabetes which she controls using Insulin. The mother does not have further health problems. The brother is 16 years old. He was diagnosed with pneumonia and he is short-sighted. The sister is eight years old and does not have major health problems apart from chills and getting a cold.

Social History

The patient claims to have taken good healthcare steps. He reports of going for checks every year. SM admits using alcohol and tobacco but claims he only does so occasionally. Patient

claims that drinking only during parties with a frequency of about twice a month. He denies use of illegal drugs. He is an active student and a member of the school’s football team. SM claims that he jogs for 5 days in a week and goes swimming twice each week. He also has a membership in a local gym where he practices for 10 hours each week. He is not on a diet but says that he watches his intake of fat and calories. He has one girlfriend and he is sexually active but practices safe sex.

Review of Systems

General

He reports to be in a state of good health. The patient denies instances of fever, fatigue, and recent weigh loss or gain. SM says that his last physical exam took place six months ago.

Skin

Patient denies changes in moles, texture or recent rashes.

HEENT, (Morreale & Borcherding, 2013), claims he has been having painful headaches especially over the last two days with a scale of about (6/10). Patient takes Tylenol after every six hours and the headache eases for a short while. He denies problem with hearing or vision. The patient claimed that he had never had any sort of hearing difficulties. SM denies use of a hearing aid or glasses. Patient states he has not had cataracts or glaucoma. He further states no instances of teary eyes, runny nose or sneezing, and does not use prosthetics. The last dental exam was conducted in 2014.

Thorax and lungs, the patient denies any lung diseases or problems with breathing. He further denies any allergies and shortness of breath.

Cardiovascular, SM denies irregular heartbeats, rheumatic fever, heart murmurs, palpitations, high blood pressure or chest discomfort. The patient affirms that he has never undergone stress test or EKG.

Peripheral Vascular, he denies cases of leg cramps, edema or coldness and skin ulcers.

Abdomen, The patient takes a regular diet. He has not had swallowing problems, nausea, food intolerance or cases of heartburn. The patient confirms that he has not experienced changes in weight. He denies cases of diarrhea or hemorrhoids. He claims that he has no problem while passing stool. SH further denies gall bladder, jaundice or liver diseases in the past.

Metabolic/ Hematologic, The patient denies instances of bruising, ease of bleeding. He says that he does not have thyroid problems, excessive thirst, hunger or any diabetes symptoms. He only got a blood transfusion once and that happened five years ago after suffering a car accident.

Psychiatric, (Gateley & Borcherding, 2012) SM denies nervousness, concentration difficulties, panicking or anxiety. He usually wakes up during the night to urinate but he relates this to his high intake of fluids, especially coffee at night. He does not have mood swings or changes. SH does not feel unhappy and does not feel the urge to harm other people. He denies cases of memory loss, excessive stress or nightmares. A friend past away seven months ago but there has been no deaths in the family.

Musculoskeletal, (Morreale & Borcherding, 2013), the right ankle was sprained two days ago and he feels constant pain around that area and the entire leg hurts. The patient claims that the ankle pain is about (8/10) on scale. He uses Ibuprofen to elevate the ankle pain but he claims it has not been effective. He denies other orthopedic injuries.

Neurologic, SH denies instances of seizures, stroke or tremors. He has only been receiving the constant headaches after suffering the ankle injury.

Objective

General appearance, the patient is a 22 year-old male who is alert, audible and talkative. He looks clean and has good clothes which fit him properly. He answers all questions without any difficulty. He appears a bit young for his age but looks healthy.

Vitals

HT: 64 inches

WT: 139.2

BP right arm while seated. 102/69

HR 72

RR 16

O2 Sat 98% on the room air

Temp 98º

BMI 23.89

Head, Normocephalic, short hair. The scalp had no lesions. TMJ full ROM no clicks. There was no frontal or maxillary sinus tenderness.

Ears, for the external ear there were no masses, lesions, tenderness or drainage.CN I intact. No bulging, erythema, landmarks appreciated bilaterally.

Nose, the septum was midline, turbinates were pink and moist. SH had no polyps, lesions or nasal bilateral discharges.

Throat and mouth, the uvula was midline, no exudates and the tonsils well aligned to pillars.

Neck, the lymph and thyroid were not palpable. The trachea was midline.

Breasts, The nipples were symmetrical and there was no gynecomastia. The palpation test showed that breasts palpation was deferred.

Heart, (Gateley & Borcherding, 2012), the carotids were not assessed. S1 and S2 were best at apex. There was no JVD at 90 degrees and no sound.

Thorax and back, the patient had normal curvatures.

Lungs, Anterior and Posterior lung fields tested clear to auscultation.

Abdomen, the abdomen appeared round with no abdominal bruits, striae or scars. No tenderness to palpation. The spleen and liver were not palpable.

Extremities, upper and lower nails had no cyanosis or clubbing. His muscles were also well developed.

Skin, his color was consistent with his race.

Lymph nodes; they were not palpable in head, neck or the groin region.

Neurologic

Mental status: appeared alert and no confusion witnessed.

Genitals, not examined.

Rectal, not examined.

Labs: TSH, T3, T$, BMP, CBC and HA1C.

Assessment

The patient should visit office level: 99214

Differential diagnosis

1. Right ankle sprain- There was little swellings and he explained that the impact had been minimal. On diagnosis to his left ankle (Tecklin, 2008), there was a measure of 729.5 of pain in limb levels, and a 729.81 swelling on the limb. The ankle was warm to touch and the patient was able to move it.

An anterior drawer test was conducted to check the amount of anterior-talar displacement suffered by the patient. The test showed that it was normal with a 3mm result.

The talar tilt test showed normal a result with 7 degree difference from the normal side.

2. Right Ankle Fracture

The patient had an X-ray taken on his right ankle to determine if there are possible bone fractures. The foot should also undergo an X-ray to check whether there may be further injuries sustained (Radomski, 2008). An X-ray of the right ankle was taken. The test results were XR ankle 3Vw.min complete, XR Foot Comp 3VW min. The history of the test was pain. On comparisons no relevant comparison studies were available. The findings were that the right ankle had no fracture or dislocation. There was no lytic or blastic. The test showed no evidence of talocaloaneal or calcaneonavicular. Based on 3 views of the foot there was no fracture or dislocation. No lytic or blastic tension, no foreign body or soft tissue gas was noticed. In regard to the results of the X-ray, the patient did not suffer a fracture or dislocation of the right ankle or the foot and therefore no plan was to be accorded.

3. Right Ankle Impingement Syndrome- Together with the X-ray tests, MR imaging and MR Arthography tests were conducted and the results showed that the patient did not suffer ankle impingement syndrome. The patient claimed that this was his first ankle sprain. Tenderness or thickening of the syovium was not detected. The dorsiflexion impingement sign was negative. The results ruled out the possibility of a right ankle impingement syndrome.

4. The patient has not been having severe headaches or joint pains before he sprained his ankle. A migraine was ruled out because the headaches started two days ago after the accident and it is more likely as a result of the sprained ankle, or it may be due to the impact of the fall.

The patient does not show signs of other possible health problems apart from the sprained right ankle.

Plan

Short-term goals in 3 weeks

The right ankle was bandaged to control swelling and advised to take adequate rest. The patient will undergo simple exercise program. The patient was advised to take physical therapy. The patient was given crutches to aid him in walking. The patient should take elevation exercises and elevate the foot above heart level for 25 minutes 3 times a day for 3 weeks to minimize the swelling. The family was informed of the importance of a proper diet and helping the patient with the exercises program. The family was informed to provide company to the patient and encourage him during the recovery process. The patient was restricted from vigorous physical activities; he was advised to stop playing football until the ankle heals and informed to avoid a fall.

The patient will get a right ankle dorsiflexion this will aid to plantar flexion to 45 degrees (Tecklin, 2008).

The patient will demonstrate 3/5 strength in the right ankle.

Long-term goals in 6 weeks

The patient will report 0/10 pain (Radomski, 2008), without use of medication or wearing a crutches.

The plan

Modalities shall include heat and ice; the patient shall apply ice for 10 minutes twice a day for 3weeks to ease the pain. Compression shall be applied by use of a bandage; the patient will apply the bandage on during the day, at night the ankle would be left to relax.

Gait training shall be performed. The patient would take mobility and body balancing exercises.

There shall be manual therapy especially in soft tissue and joint mobility.

Medication

The patient should take Motrin 600 mg Tab 1 tablet Q 6-8 hours to help ease the pain. The patient should take Ibuprofen 200mg after 6hours daily for one week for the headaches, and advised that a side effect such as gastrointestinal upset was possible.

The patient should return to the clinic after every three weeks for a period of two months to follow up on his recovery. The patient was further advised to visit the clinic anytime in case there was no improvement or the signs and symptoms increased before the 3 weeks duration. The assessment and the plan patient were discussed with the patient and he agreed to them. The patient was optimistic about a quick recovery.

References

Ankle Sprains and Fractures in Adults. (n.d.). Orthopaedic Nursing, 321-322.

Gateley, C., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK.

Morreale, M., & Borcherding, S. (2013). The OTA's guide to documentation: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK.

Radomski, M. (2008). Occupational therapy for physical dysfunction (6th ed.). Philadelphia: Lippincott Williams & Wilkins.

Tecklin, J. (2008). Pediatric physical therapy (4th ed.). Philadelphia: Lippincott Williams & Wilkins.